=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104398700
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHAYA SOLOVEITCHIK BCBA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/19/2018
-----------------------------------------------------
Last Update Date | 12/19/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 126 MELVILLE AVE
-----------------------------------------------------
City | LAKEWOOD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08701-4235
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-910-2924
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12 ASPEN CT
-----------------------------------------------------
City | LAKEWOOD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08701-4332
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-263-0800
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number | 1-18-31035
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------